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Tennessee Valley Gastroenterology, LLC

Details

Name: Tennessee Valley Gastroenterology, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Exists
Date of registration: 26 Apr 2002 (23 years ago)
Entity Number: 000-681-823
Register Number: 000681823
County: Lauderdale
Place of Formation: Lauderdale County
Principal Address: FLORENCE, AL
Registered Office Street Address: 416 N SEMINARY STFLORENCE, AL 35630
Registered Office Street Address ZIP Code: 35630

Activities ANY LAWFUL ACTIVITY

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1093851313 2007-01-30 2017-05-09 416 N. SEMINARY STREET, SUITE 3100, FLORENCE, AL, 35630, US 416 N. SEMINARY STREET, STE 3100, FLORENCE, AL, 35630, US

Contacts
Phone +1 256-766-8667
Fax 2567675327

Authorized person
Name DR. JASON WILKES
Role OWNER/PHYSICIAN
Phone 2567668667

Taxonomy
Taxonomy Code 174400000X - Specialist
License Number 00006975
State AL
Is Primary No
Taxonomy Code 207RG0100X - Gastroenterology Physician
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 051521216
State AL
Issuer MEDICAID
Number 529919960
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
TENNESSEE VALLEY GASTROENTEROLOGY LLC 401(K) PS PLAN 2012 020593578 2013-06-10 TENNESSEE VALLEY GASTROENTEROLOGY, LLC 9
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 2567668667
Plan sponsor’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631

Signature of
Role Plan administrator
Date 2013-06-10
Name of individual signing GERARD D HAGGSTROM, MD
Role Employer/plan sponsor
Date 2013-06-10
Name of individual signing GERARD D HAGGSTROM, MD
TENNESSEE VALLEY GASTROENTEROLOGY LLC 401(K) PS PLAN 2011 020593578 2012-09-24 TENNESSEE VALLEY GASTROENTEROLOGY, LLC 9
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 2567668667
Plan sponsor’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631

Plan administrator’s name and address
Administrator’s EIN 020593578
Plan administrator’s name TENNESSEE VALLEY GASTROENTEROLOGY, LLC
Plan administrator’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631
Administrator’s telephone number 2567668667

Signature of
Role Plan administrator
Date 2012-09-24
Name of individual signing GERARD D HAGGSTROM, MD
TENNESSEE VALLEY GASTROENTEROLOGY LLC 401(K) PS PLAN 2010 020593578 2011-10-12 TENNESSEE VALLEY GASTROENTEROLOGY, LLC 9
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 2567668667
Plan sponsor’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631

Plan administrator’s name and address
Administrator’s EIN 020593578
Plan administrator’s name TENNESSEE VALLEY GASTROENTEROLOGY, LLC
Plan administrator’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631
Administrator’s telephone number 2567668667

Signature of
Role Plan administrator
Date 2011-10-11
Name of individual signing GERARD D HAGGSTROM, MD
TENNESSEE VALLEY GASTROENTEROLOGY LLC 401(K) PS PLAN 2009 020593578 2010-09-29 TENNESSEE VALLEY GASTROENTEROLOGY, LLC 9
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2003-01-01
Business code 621111
Sponsor’s telephone number 2567668667
Plan sponsor’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631

Plan administrator’s name and address
Administrator’s EIN 020593578
Plan administrator’s name TENNESSEE VALLEY GASTROENTEROLOGY, LLC
Plan administrator’s address 416 N SEMINARY ST, SUITE 3100, FLORENCE, AL, 35631
Administrator’s telephone number 2567668667

Signature of
Role Plan administrator
Date 2010-09-27
Name of individual signing GERARD D HAGGSTROM, MD
Role Employer/plan sponsor
Date 2010-09-27
Name of individual signing GERARD D HAGGSTROM, MD

Member

Name Role
HAGGSTROM, GERARD D Member

Agent

Name Role
HAGGSTROM, GERARD D Agent

Related by officers

HAGGSTROM, GERARD D

Florence Clinic, L.L.C.

Related by address

FLORENCE, AL

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416 N SEMINARY STFLORENCE, AL 35630

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Date of last update: 15 Aug 2024

Sources: Alabama Secretary of State

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